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a. qulh•,_d� • <br /> ,.._�j .9.� SAN JOAQUIN COUNTY FILE GP Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> �•'. '�l 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: 209 UNIT IV p ( ) 468-3147 Fax; (209) 468-3433 Web:www.sigov.org/ehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the <br /> �l'Standards of the San Joaquin County Environmental Health Department. <br /> Site Location ` qO �eecl���,t fLCrSssStreet tfuC-5+ QLto �/r City/State lt <br /> ip 1537te APN 2-34OTI�US. <br /> Property -� ��" 1 p I <br /> Owner CAtx ayl Addresswol r7o1at1{,X-e t�a�l. Ct /Sity/State I�+l+`� llz'ip W583 Phone125-71Q'Lg3/ <br /> C-57 Contractor�eAe Car Address kZr�F T��iGe- 5-- -� -[P r•1 City/Statew°���wt�c 9o(e 9 Phone 530-C&041013 <br /> ConsultanUSub Cntr Address ?,[Of W426fe-11M­ FIr•12-City/State 6,k)0 S Lic (00, q O Phone 5(d <br /> Billable Party CL-txvTxy - Address�16( ity/Statekn ma ip I15T.3 Phone 1Z5-tea" q31 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> [jPNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> Q SOIL BORING IDs <br /> ❑WELL IDS <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [> No(MAXIMUM FREE FALL DEPTH IS 30 FT) 1 <br /> _❑INJECTION(i a.Air Sparge.Ozone) HAND AUGER GROUT SPECIFICATIONSI t�j(�t V ( ?eiy' 1--".1 C GI✓1 e— / <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH S"5 1 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: !_ <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify tha ve p re i lication and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulation I lic Cali I � <br /> Signed Title/Company C— <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �b a6e NuuT AV& TR.M q <br /> WORK PLAN DATED F B Q /U LP(4 <br /> APPLICATION ACCEPTED BY DATE ISSUED 2-Z6j0'y AREA_ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> p ? REQUESTQ PR# <br /> I <br /> $125.-A --,, �Z.� J 35- 6 Ccu -1041 SR# 1 <br /> RO# <br /> 3500 <br /> PR# <br /> (2900 <br /> C-57 WC V, WAIVERU V� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ��ENCROACHMENT DO&4 <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />